Sunday, July 31, 2011

Lost in the Big Picture

There was something I started to add to yesterday's post, decided it was best to hold off, and I'm glad I did because it gave me something to write about this morning. It concerns the treatment given free will in The Adjustment Bureau. In this film, the caseworkers (see 7/30/11) tell Matt Damon's character they've taken over managing human affairs because we've botched the job whenever they've given us the opportunity to do otherwise. To justify their position, they refer to our darkest and worst times, e.g. the Holocaust in Europe during the 1930s and 40s.

Their approach is similar to the one I've heard used as an objection to theism, the idea that God is personal (may be engaged in relational terms) and more specifically, to Christianity. If an all-powerful God exists and this God is good, then how could such a being permit ______ (you fill in the blank)? The implication is we humans at least possess good intentions and if we could prevent vile things from occurring, we would.
Therefore, presence of evil indicates God either does not exist or s/he is not good. If God merely lacks the power to act, s/he is not of much use and frankly, I'd agree. Most gods are too small, anyway.

But what if evil is a matter of opinion and the problem lies in perception? Well, to really qualify as evil and not simply as bad or inconvenient, something has to be so bad that any conceivable world would be a better one without it. Famine, pestilence, and environmental degradation strike me as good examples. Things that have the potential to bring about irreversible damage, rendering life less tenable. Evil has to be more than semantics, otherwise we're just playing word games.

Now, back to the caseworkers. They cheat because they paint our misuse of free will in broad strokes, blaming us for the Big Evils while conveniently ignoring the little ones. If they're really nudging and guiding us along to fulfill the intentions of The Plan like they say they are, why do we hurt each other so often? What about the fellow who robs a little old lady on the street or guns down an innocent bystander in a shoot out with police? I know, they said there aren't enough of them to ensure chance events don't happen once in a while, but they also said those occasions are generally insignificant. If that's true, who's minding the store the rest of the time? If they're doing the nudging and we only think we possess free will, then it seems to me we're off the hook. We've got one massive King's X when it comes to being blameworthy and they've got some serious explaining to do.

For me, what it comes down to is, either I'm free to be a bastard or God or the Devil make me act like one. Maybe I'm slow on the uptake, but I don't see a whole lot of other options. True, how could I know if someone else was directing my actions, particularly if I never saw or had any communication with them? I'd have to be able to stand outside myself, observe my behavior, and measure it against some relatively objective standard, to say whether or not I was acting on my own or as a puppet. And in fact, isn't that what we do when we call someone into court, compare their actions to lawful ones, and then decide innocence or guilt with whatever objectivity we can muster? Even if free will turns out to be a fiction, we have to presume it is not, if we're going to hold each other accountable for our actions.

Black and white turns interminably gray at this point because none of us are as free as we would like to be or as would like to think we are. Personal baggage, unconscious or not, influences decisions and behavior, and it's the recognition of this fact that forms the basis for mercy. Extenuating circumstances, errors in judgment, simple stupid mistakes, are part of life and perfection is a far off ideal for most of us. The caseworkers got lost in the big picture; grace is found in the pixals. Enough of them and you've got a snapshot, but you have to see them to see the whole story. I guess it takes a human to do that.

(Creative Commons image entitled "Angel" by just Luc via Flickr)

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Saturday, July 30, 2011

Fate, Freedom, or Both

Do you believe in fate?

Not really, I'm more of a dumb luck kind of gal.

These are the final lines spoken in Source Code (2011), a film I've heard described as a thinking person's science fiction story. "Think" is what it made me do and it's the second film in the past week to have that effect. The first was The Adjustment Bureau (2011) and both raise the question, is there really such a thing as chance?

Source Code sets up a scenario in which an event is repeated until a desired outcome is achieved, suggesting what appears as chance may be the by-product of someone or something working behind the scenes. Jake Gyllenhaal as Captain Colter Stevens, is a helicopter pilot KIA in Afghanistan, whose conscious identity has nevertheless been salvaged. Because eight minutes of neural processing remain active and accessible following physical death, a new scientific process enables uploading of Stevens' residual consciousness into the body of a passenger killed in the bombing of a commuter train bound for Chicago. His mission is to find the bomber before s/he can set off a second device downtown. Reminiscent of Bill Murray in Groundhog Day (1993), the success of Stevens' mission requires practice and he must experience his borrowed body dying several times before he can accept the reality of what's happening to him.

As a subplot, Stevens becomes involved with a young woman played by Michelle Monaghan. Unaware they are reliving their final eight minutes over and over and possessing no memory of the experience, she views the attraction between them as spontaneous. In reality, it's an outgrowth of what Stevens learns about her from each previous leap onto the train and expresses in each subsequent leap. In Source Code, what appears as chance is a matter of perception.

The Adjustment Bureau brings Matt Damon and Emily Blunt together as potential lovers by what also seems to be happy coincidence. In this film, however, they were predetermined to be together by a master Plan, composed and set in motion by an unseen character known only as The Chairman. One might expect such a Plan to be inviolable, set in stone, but from time to time, The Chairman has been known to revise it. Although earlier versions have Damon and Blunt living happily ever after, most recently, The Plan indicates "other plans" for them. Their budding romance is considered a mistake and individuals known as caseworkers, who have the duty of implementing The Plan to the letter, intervene.

According to The Adjustment Bureau, chance sometimes slips through the cracks. There are just too many people for too few caseworkers to monitor all of the time, but the effects of chance and free will in most circumstances are pretty limited. Whenever we've been allowed to try running the whole shibang, we've done very badly. The Holocaust, two world wars and the Dark Ages are proof humans lack the maturity and judgement to make choices that don't end in destruction. To prevent us from ultimately destroying the entire planet, the caseworkers have taken over, nudging us this way and that. When persuasion doesn't work, they have the ability to alter our thinking, leading us to make choices more in line with the direction The Plan intends. 

Most people, we're told, are happy enough not knowing their choices aren't free. Security and predictability come at a price and they're willing to pay without a second thought. Now and then, however, someone comes along who needs to know who's pulling the strings and why. For Damon, however, knowing, in and of itself, resolves nothing. For him, love validates the exercise of free will.

But free will is complicated. What we believe to be fully conscious intentionality is more often than not a reflection of the genetics, adaptive behaviors, thoughts, and impressions derived from family and culture, albeit individually processed, packaged, and marketed as "us." Choice is conditionally free; the conditions under which it develops influence its exercise. Those influencing Damon and Blunt include previous versions of The Plan. 

Interestingly, their meeting was prearranged. For Damon's character to achieve the destiny set forth by The Plan, he needed her as inspiration to rise out of a moment of defeat. Once she'd done as the caseworkers intended, that was to have been the end of it. Their ongoing relationship resulted from the desire of one caseworker to give free will another chance. By acting in contradiction to The Plan, he created a space in which Damon and Blunt could take their lives in their own direction. Even if it turned out to be the one chosen for them, long ago.

Is there such a thing as fate? I sometimes think so, though I'd be hard pressed to demonstrate it empirically. But my own ability to snatch defeat from the jaws of victory and sometimes the other way around, is sufficient proof to me, that free choice hasn't completely abandoned the field. I still think it comes down to what we do with it, fate, freedom, or both. Hopefully, it's something good.

(Creative Commons image entitled "Reversible Destiny" by scarletgreen via Flickr)

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Friday, July 29, 2011

Enter the Dragon

Typewriter adler3Image via Wikipedia
Once upon a time, people took Typing Class in high school. Back then, typewriters came in two varieties, manual and electric. Manual typewriters depended on the force of the downward keystroke to produce an inked impression of letters, numbers, and punctuation marks on paper. Regular use of one of these would have been great finger- strength training for rock climbers. Electrics yielded similar results but with less force required resulting in less operator fatigue. They were also more expensive and, naturally, absolutely useless without a power source. Batteries were not included and it wouldn't have made any difference if they were, electrics didn't run on them.

Then came the word processor. Actually, first came the crossover, an electric that had a line or two of memory built-in and played catch-up with the writer. Then came the word processor, initially allowing one to compose and edit a paragraph before printing. As time went along, whole pages could be stored in memory. And finally, Steve Jobs got a better idea, though I'm sure there were others involved in turning out the personal computer, I just think of him because of the Mac.

So, that brings us to the present moment, when I sit in my late father's slightly askew office chair with a Dell Latitude laptop on my lap (where else?), the puppy in his crate destroying a plastic water bottle, and the big dog at my feet trying to do what I wish the puppy would, namely, sleep. Enter the Dragon and I don't mean Bruce Lee.

Dragon software is voice recognition. My first exposure to it was via an app for my iphone that allows me to speak the name of a drug or condition into a microphone and watch as it turns out a list of accessible current references. While I was doing my psychiatric rotation, I learned there was a version marketed for clinical documentation. The system isn't perfect -- right now, Dragon is slower than transcription services, but we're only in the first quarter. As soon as the software can keep up with rapid-fire dictation, reducing hospital operating costs will take precedence over paying transcriptionist salaries.

What triggered this post was a television commercial I saw this morning while the dogs were eating. Dragon software is available for personal computers at a hair under a hundred bucks, a hair under eighty if you call during the next sixty seconds -- operators are standing by. Sorry, they lost me before I got the number.

Anyway, one of the actors was a young woman who stated she didn't know how she ever blogged before getting Dragon. Now, she said, her blogs sound like conversation and she's oh, oh, oh so happy she feels like twirling around on her virtual mountaintop, singing, "The hills are alive, with the sound of music!" Well, maybe she wasn't quite that perky, but darned close. It must have been just then my finger found the channel button because I can't remember anything else. Aren't you glad?

Realizing this probably sounds as dated as the ratataptap of an old manual typewriter, I still like writing that involves the mind-body interface. I "hear" the words in my head and my fingers do the rest. And to tell the truth, I don't really express myself orally as lucidly as on paper. You might find that hard to believe, coming from a minister, but not all my fellows in seminary had silver tongues. Sure, there were a few, but prepared sermons are one thing, blabbing away on the fly is another. I need the delay between thinking and writing to keep my foot out of my mouth and even then, I'm not always successful. I'm sure Dragon has its place and the day may come when talking about a laptop with a keyboard will make my kids roll their eyes. As long as they read what I write, it's okay by me.

(Creative Commons image of an Adler typewriter keyboard via Wikipedia)

Saturday, July 23, 2011

It's Called Direction

Henry David Thoreau
How does it feel, having completed my psychiatric rotation? Satisfying -- especially since a scheduling shift allowed me to tack on another week at the end -- and I think I may have learned something about ordinary living that I hadn't anticipated. Henry David Thoreau wrote, "I went to the woods to live live deep and suck all the marrow out of life." I've endeavored to do likewise, drinking at the fountain of each day. knowing the rotation I've waited four years to experience, would pass like a thief in the night, whether I left the front door unlocked or not. Though it may not seem like much, when you're trying to be fully aware, feeling each moment, allowing it to fill you up and splash over like water overflowing a bottle, five days can equal five lifetimes.

And that's what I tried to do with every weary night's walk from A-3 (adult psychiatry) through the behavioral intensive care unit, down the hallway of the Center for Joint Replacement, then up the stairs to the chemical dependency unit to return the key I'd checked out that morning. The key that gave me ready access to office space for interviewing patients. The key that spelled independence, freedom to spend my time going, doing, accomplishing, instead of watching it trickle through my fingers, waiting. The key like one carried by staff members, by doctors, that signified I was one of them and my work meant something. And not just to me.

A quick goodnight, see you in the morning later, and it's down four and a half flights to the ground floor, past Dunkin' Donuts and out the sliding glass doors marking the main hospital entrance. My car is parked two blocks away and in the heat, it's a long two blocks. People I've never seen glance at my tie and smile in greeting. Nurses, assuming one of the doctors is heading home. An internist, driving by in his Thunderbird convertible, waves. It might be late, it might be early, but I look right at the stoplight and see the hexagonal wooden tower that houses the A-3 dining hall framed against the western sky. I'll see you tomorrow, I whisper.

But Monday's tomorrow, I won't. Instead, I'll be preparing to drive north once again, past the familiar turnoff leading to the tiny burg that was my home for rural medicine, and on to Bangor where Internal Medicine begins in another week. I've got a context now that I didn't have seven weeks ago. Rather than simply learning more medicine, gaining skill like a professional Monopoly player, I'll be learning about the underpinnings of psychiatry in the guise of you name it. I'll exchange my shirt and tie for blue-green scrubs, tennis shoes, and a white coat.
Conditions like delerium that I've helped diagnose, now I'll help treat.

But not with a questioning mind uncertain of its goal -- that ship has sailed. Five minutes on the psych unit, I was standing on the dock, waving a hankie and bidding it bon voyage. Everything that is to come is training to be a better psychiatrist, one who can keep a patient alive until the code team arrives if he has to, one whose stethoscope sits on the desk next to a dog-eared copy of Freud's Psychopathology of Daily Life. One whose patients aren't hesitant to call their doctor. More than a context, it's called direction.

(Public Domain image of Henry David Thoreau via Wikipedia; citation from Walden)

Monday, July 18, 2011

"Hard" Wood Floors

"I found him first!" said Jake, proudly. "I sniffed and licked and made it all better." Actually that's not quite how things went, but as Jake was first on the scene, I'd say it's close enough for government work. I wish his licks had made it all better so I didn't have to spend the day hobbling round the hospital, but he was well-intentioned and I welcomed his support.

What happened was, I'd entered my study this morning to open windows and let in the morning breeze, such as it was. I didn't bother with a light since I thought I could see where I was going. So, there's this metal fence type of thing that I connect to Jake's crate on days when the dogs have to be alone, giving him an indoor "yard" where he can have potty papers. I'd folded it up and leaned it against an end table out of harm's way. Famous last words. When I turned away from the window, my right foot caught a corner and you can imagine the rest. A flight like that is not one I'll be eager to repeat anytime soon.

I remember stepping into a snow bank once, high up in the Rockies, and thinking, as my knee twisted and I went down, "So, this is what it's like to break a leg." I didn't, miraculously, but the memory has stayed with me. There was no premonition of personal damage this morning and I think it's because I didn't have time to think or was too caffeine-deprived.

At any rate, lying there on the knotty pine floor with Jake inspecting me like a medic on the battlefield, I stretched a leg, then palpated my rib cage -- no fractures. My head, on the other hand, is so hard I was more concerned about the floor. It's funny how we hurt more after the bruises start to appear than we do at the moment of impact. And that's how it came about that I spent the day nursing a sore knee and rubbing an even sorer set of left-sided ribs (numbers four through six for inquiring medical students/residents).

I did learn one thing from this experience, however, that I'd like to pass along. They don't call them hard wood floors for nothing.

(Creative Commons image entitled "Flight" by k-girl via Flickr)

Sunday, July 17, 2011

Not Just a Pretty Face

"It's not easy, being green." ~ Kermit the Frog

Kermit's been my favorite Muppet ever since the opening scenes of the The Muppet Movie (1979) depicting him sitting on a log in his swamp, singing, "The Rainbow Connection." I love that song, especially the final verse.

Have you been half asleep,
and have you heard voices,
I've heard them calling my name.
Is this the sweet sound,
that calls the young sailor?
The voice might be one and the same.
I've heard it too many times to ignore it;
it's something that I'm supposed to be...
Someday I'll find it, the rainbow connection,
the lovers, the dreamers, and me.

Kermit's right, it's not easy being green -- or whichever color you happen to be. I don't mean skin and I don't think he does, either. It's not easy being a frog, amphibian on the outside, singer of songs on the in. People don't readily adjust to either. A talking frog or one with a dream. Frogs are supposed to croak, or creak if they're the teensy tiny ones populating the imitation Everglades a few hundred feet from my house. There's a whole chorus of them, all on key, all on the same note, probably all saying the same thing, all at once. Yeah, that's what frogs are supposed to do.

Not sing. Not while playing a banjo, anyway.

I've felt like Kermit lately. I mean, you'd think it was the most natural thing in the world, to tell people in a psychiatric department you've been down their road before, picking up twigs and stones of this and that along the way, shoving them in your pockets like a kid collecting treasures. But it's not always, and there's a whole slew of reasons why. The last thing you want to do, ever, is create the impression you think you're past being a student. For one thing, it's not true and on top of that, even the things you do know can be and probably are, done differently and maybe better.

Another reason is, you're as unknown to them as they are to you. They're busy doing their jobs and even though that includes teaching you, it takes a while to figure out how loosely they can hold the reins. They know the individual patients you're working with and even though you may have seen similar ones before, you haven't seen these ones and only a fool ignores his guide in the wilderness.

Besides, gradual acquaintance pays dividends. Think about the last time you went out with someone who practically told you their life's story on the first date. It's really more fun if something is left to the imagination. All except, of course, the fifteen semesters they spent learning license plate decorating in San Quentin. You'd like to know about that up front.

It's kind of similar here, where allowing yourself to become known bit by bit makes things more interesting. But then comes the day when when someone discovers you and your friends wrote a book and it looks like you've been keeping secrets. You weren't really, you just wanted people to get to know you so that what you've done doesn't get in the way. So they know you're a regular guy and not just a pretty face.

No foolin'.

(Creative Commons image of Kermit by kewgee via Flickr)

Saturday, July 2, 2011

It's the People, Not the Place

If I were to say it's harvest time, you might glance at the calender and wonder if I didn't need some of the chemical dependency treatment I've been trying lately to provide, except for one thing. My hayfield is getting its first buzz-cut of the year. In a couple of months, we'll get one more "cutting," before the growing season settles in for a long winter's nap. All of this means the sound of a tractor engine is added to the bird songs coming in my study window, blending with the rhythmic inhalation-exhalation cycle of sleeping dogs. These are the sounds of Maine mid-summer mornings I love best.

They are especially nice when heralding the onset of a three day weekend. I know, you thought I couldn't wait to get to the psychiatric unit each morning, what gives? Well, Saturday morning reverie like this feels like pushing yourself back from the table after a holiday meal with family and close friends, a meal with all the trimmings that satisfies like no other. The past four weeks I've tucked in with a huge napkin draped over my shirt and my plate has overflowed.

If I were called in, I'd be glad to go, but that's not going to happen. Students don't have "call" on this rotation, so I'm spared the necessity of being available, though like I say, I wouldn't mind. One of the docs has the duty this weekend and he'll cover the adult, child-adolescent, and chemical dependency units. Basically, he needs to touch base with every patient once in the course of 72 hours and take care of emergencies and new admissions. But I remember my first night on-call during pediatrics and this is his first weekend in the same role, only with more responsibility, and it's easy to commiserate. Besides that, he's a really nice guy whom I've enjoyed getting to know.

That holds true for everyone I've worked with thus far. I realize I've said this before, but it's hard to say too often. I'm truly grateful for the generosity these people have demonstrated, how they've taken me in as a quasi-staff member, overlooking my occasional and predictable mistakes, and accepted my efforts to do well with appreciation. For all the reasons I'm not looking forward to the end of this rotation, the people I've worked with are at the top of my list.

I think the reason for this comes about from a paid employment history that includes two hospitals. I've been a member of a treatment team where people are counting on me to do my job. Medical students are permitted certain tasks but none of them are essential in the sense that, in your absence, there is no one else available to do them. On this rotation, however, the entire staff, from the unit secretaries to the physicians, have not only treated me like someone they enjoy having around, they've taken my contributions seriously. They make me wish this hospital had a psychiatric residency program.

One of them, a social worker, does something no one else has ever done -- he insists on calling me "Doctor." Not "Student Doctor," but Doctor in the same way, with the same tone of voice he uses when speaking with the psychiatrists. I told him one evening, as he was preparing to leave and I was still at the computer, writing progress notes, that getting into medical school had been a struggle and staying in was a full-time job. Even though I had no legal right to the title, it meant a great deal to hear him use it. He ducked his head, smiled, and said I deserved it. That blew me away.

I'm not sure I deserve anything, really, but working with folks like him makes me realize, when it comes to being happy, more than anything else, it's the people, not the place.

(Creative Commons image of the Joint Medical Group by Defense Images via Flickr)
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